Wherein a surgeon tells some stories, shares some thoughts, and occasionally shoots off his mouth. Like a surgeon.

Friday, September 21, 2007

Signs

I mentioned signs in a recent post, at the time referring to those unofficial (as opposed, say, to Battle's Sign) but somehow meaningful constructs we all get to know. To wit:

The "O-Sign," signifying a level of coma such that the person's mouth is open.

The "Q-Sign," meaning the same, with the tongue hanging out. More serious.

The "Lipstick Sign," when a lady puts on makeup/lipstick after surgery or other illness, signifying recovery. I suppose a male equivalent is shaving.

There are many others. (Throckmorton's has already been done.) And I've seen a few compendia of abbreviations. Here, I'm thinking signs.

It needn't be medical. Got any amusing or dead-on signs to add, relating to your profession? In particular, anyone ever come up with one of his/her own? I think I did.

I used to refer to Schwab's sign (of imminent death): when the hematocrit and bilirubin cross. I think, in fact, it might also apply to hemoglobin/bilirubin. For all I know, it's already been named; but I haven't heard it. What're yours, new or used?

Dr. Schwab,What a cool post!:) I think that the ultimate sign of sincerity is eye contact. The eyes reveal the heart of a person. Along the same lines isn't a visual sign, but an ultimate sign that I learned in my coma - a person's voice. Everything, the essense of a person, is in their voice. Their voice reveals what they don't even know about themselves.

My younger kids sit on their hands if they've done something they're not supposed to and they know I'm onto them, and they hold their faces perfectly still if they're eating candy or something they know they're not supposed to. My oldest son starts to giggle if he's hiding something because he knows his laugh melts my heart and he'll get in less trouble (so I know to start searching for what he's done wrong). People's actions always reveal where their minds are at. The southern Sudanese can determine whether or not to accept someone into their tribe (by marriage) by the courage they have in standing up to the elders. They determine everything on facial expressions, eye contact, words, etc. A person's resolve and strength can often be seen in their posture and how they hold their jaw. How fun!

Chandelier signAlso known as 'rebound tenderness'. When you push your hand hard into a peritonitic abdomen and then let go, the patient can be found clinging onto the chandelier or whatever light fixture you have in the examination room. Which is why rebound tenderness should be tested by gentle percussion of the abdomen.

When I was a resident, one of the cardiac surgeons used to point out the "farm girls" and "silk pillow girls" among his (mostly elderly) patient population. The farm girls were easy to spot. They were sitting up on the side of the bed the day after their CABG, ready to get moving. These were (as he described it) women who grew up on a farm, in a big family, who spent their lives taking care of large groups of people and had no time for being laid up in bed.

The silk pillow girls, on the other hand, were the ones who showed up at the hospital clutching the special pillow they always sleep with at home. You knew they were going to be around for a while.

Not so much a sign, but our pathology professor in vet school often talks about the samples coming through necropsy with no history other than "ADR, x2 weeks." Someone finally asked, and we were told what I'm sure we'll hear for the rest of our careers ---- "Well, the dog/cat/horse/etc just Ain't Doin' Right."

birth plan sign (or doula sign, can be used interchangably): The sign that a patient inevitable prolonged labor, induction, chorioamnionitis, followed by four hours of pushing and a failed vacuum assisted delivery which will shortly be followed by a cesarean section.

The universe, in its irony demands that mothers who want to have normal, uncomplicated, less-medicalized labors will be have the ironic misfortune of having every intervention (maximal obstetric intervention) and most of the common complications. Particularly when they taunt the fates by writing their desires down.

(don't get me wrong, I'm happy for people to have whatever birth experience they want, it just seems that the more you write it down or if you bring a doula with you, it's bad luck).

Not exactly a sign but nonetheless a nonverbal communication: a man walked into the ER when I was an intern, went up to the desk. When he was asked why he was there, he just turned around showing a knife sticking out of his back. Without even taking a history it was clear this was a domestic squabble, since it was a serrated kitchen knife.

Positive Humphrey Test (named after a friend from medschool) = a patient who looks healthy yet has at least one positive hit in every category of the Review of Systems. This Test has a strong predictive value for psychiatric disturbance.

That familiar GI Bleed smell that hits you as you pass a patient's room . . . along with C Diff colitis.

The Trauma Paradox = the probability of survival is inversely proportionate to the patient's value to society.

In the UK we talk about the 'Seagull' sign - if the heart rate is above the systolic BP (looks like the seagull is crapping upwards on the obs chart) then the patient is pretty much in the crap too.

Totally agree with the Humphrey test - beware the 'Yes' sign - the patient that says 'yes' to everything you ask in the Review of Systems. Can be tested for by asking the patient if they get a burning sensation in their right nostril when they urinate, or something similarly nonsensical. 'Yes' sign positive is indicative of psychiatric illness, or more specifically, somatisation disorder.

Isn't the earlobe crease a soft sign for coronary artery disease? So might be some truth there.

Here we talk about 'The Rule of Fives' in the ICU - more than five tubes entering the patient implies a poor prognosis.

Like the Lipstick sign too - when I've been unwell in the past my equivalent has been the contact lens sign. I'm blind as a bat but hate wearing my glasses - so will insist my lenses be put back in at the earliest opportunity - even if my husband has to do it for me. Bemoaning the fact that ICU does not have a patient toilet or shower is also taken by my doctors to be a good prognostic sign!

Hope these keep coming - very interesting to see that they seem to cross the Atlanic for the most part too (although not the haemoglobin/bilirubin one - think our units must be different?).

Not quite a sign, but not to forget that common treatment for the elderly breathless patient whose chest X ray is just a bit... fluffy-looking... that 'hedge your bets' therapy, 'nebulised coamoxifruseaparin'

A patient who brings his or her own radiology studies to the initial clinic visit might demonstrate "the CAT Scan olfactory sign." This occurs when the physician pulls the scans out of the jacket and they reek of cigarette smoke from sitting in the patient's car for the prior couple of days. It means that the physician has little to no chance of getting the new cancer patient to give up smoking.

A couple I forgot. The patients pain tolerance, especially to needles is inversely proportional to the number of tattoos he/she has. Also, if the patient is an IV drug abuser, they will be nearly unable to tolerate being stuck with a needle.

The easiest patient to operate on is the woman over the age of 70. They seem to have teh best pain tolerance of anyone. Men over the age of 80 are also this way. The worst? A hernia repair on a 20 year old male who lifts weights. He will be incapacitated for a month.

love this post. re: the Humphrey sign, we used to say that the patient had a "Positive Review of Systems" or Positive ROS. Since everything was positive, if that were the case then the final question we would ask to CONFIRM would be "Do your teeth itch?"

I don't have a name for this next sign but if a patient comes in with an unknown diagnosis you can be assured that the nicer the patient is the worse the diagnosis and/or the poorer the prognosis will be.

migrating pain sign? when a patient describes a pain running down the arm, then jumping to the contralateral hip, then moving up to the neck. indicative of imminent exam for which patient hasn't prepared well enough.

A corrolary to the 'Lipstick' sign is the Cranky Sign. The crankier my patients get, the closer they usually are to discharge. It takes a lot more energy to be cranky than most people realize, and truly sick folk just don't seem to have it.

I am a psychiatric social worker who does crisis evaluations and answers crisis calls. We always say that when we get a crisis call from a male caller who begins his end of the conversation with "hi, how are you doing?", that's a clear indication of Antisocial Personality Disorder. He sets out to manage the conversation from the first moments and run it in his way. The moment we refuse to engage in social chit-chat with him, the antisocial traits show themselves in full force! Then, there's always the flip side of the crying female caller who does not even say hello or introduce herself, but goes right to "I'm thinking about cutting myself." Ding ding ding! Borderline Personality Disorder arriving! When we are proven correct, it always gives us a little self-satisfactory sense of smugness (till the next time we are proven wrong, of course.)

My husband is a driver for Triple A's Roadside Assistance Program and has noticed an inverse relationship between the material signs of affluence in the vehicle he is towing (i.e, late model Hummer, Mercedes, etc. vs. a beater Chevy pickup truck) and the likelihood of him getting a tip.

People with Mercedes,etc. will hover over the car, tell him how to do his job, and act as though his one desire is to commit "accidental" vandalism.

Someone with a beater that clearly needs some stuff fixed/has the mirror held on with tape, etc, and is clearly working class is way more likely to say, "Here you go, man" and hand him a couple bucks.

About Me

Boring, Unoriginal, but Important Disclaimer:

What I say here is as true as I can make it, based on my experience as a surgeon. Still, in no way is it intended as specific medical advice for any condition. For that, you need to consult your own doctors, who actually know you. I hope you'll find things of interest and amusement here; maybe useful information. But please, please, PLEASE understand: this blog ought not be used in any way to provide the reader with ideas about diagnosis or treatment of any symptoms or disease. Also, as you'd expect, when I describe patients, I've changed many personal details: age, sex, occupation -- enough to make them into no one you might actually know. Thanks, and enjoy the blog.